Lung cancer is the leading cause of cancer deaths worldwide, causing
more deaths than breast, colon, and prostate cancers combined. Non-small cell lung cancer (NSCLC) is
the most common type of lung cancer, accounting for roughly 85% of lung
cancers.

A large proportion of patients with lung cancer are elderly,
over the age of 65, and are often poorly represented in clinical trials,
undertreated, or don't receive aggressive standard treatment due to
concerns about their ability to tolerate aggressive treatment regimens.

While elderly patients are not different than younger patients in their
willingness to accept aggressive treatment, even elderly patients with
good performance status and lack of comorbidities are less likely than
younger patients to be offered aggressive treatments on the basis of
age.

Radiotherapy is the standard treatment regimen for locally advanced
NSCLC, but can lead to esophagitis and radiation pneumonitis, which are
potentially life-altering toxicities of thoracic radiation.

A group of researchers in the United States conducted a study to
evaluate elderly patients undergoing definitive lung radiation to assess
how the elderly tolerate treatment compared to younger patients.
Patients undergoing definitive radiation for lung cancer with or without
chemotherapy from 2004-2013 were identified from a prospective
institutional database in which patients of all ages were eligible for
inclusion (UM cohort).

Patients were excluded if they were treated with
stereotactic body radiation therapy (SBRT) or if complete dosimetric
information was not available for review. Logistic regression modeling
was performed to assess the impact of age on esophagitis grade ?3 or ?2
and pneumonitis grade ?3 or ?2, adjusting for esophageal and lung dose,
chemotherapy utilization, smoking status, and performance status. The
analysis was validated in a large cohort of 691 patients from the
Michigan Radiation Oncology Quality Consortium (MROQC) registry, an
independent state-wide prospective database.

The results of the study published in the Journal of Thoracic Oncology,
the official journal of the International Association for the Study of
Lung Cancer (IASLC), reported that there were 179 patients extracted
from the UM cohort, of which, after exclusions, 125 patients with lung
cancer were included in the analysis. The median age in the UM cohort
was 66, with 34% of the patients older than 70. Among the 125 patients
in the UM cohort, 49 (39%) experienced grade ?2 and 14 (11%) experienced
grade ?3 esophagitis.

Of the 125 patients, 82 patients were <70
years old and 48% experienced grade ?2 and 16% experienced grade ?3
esophagitis. Conversely, among the 43 patients age ?70, these rates were
23% (grade ?2) and 2% (grade ?3). Multivariate regression modelling of
the UM cohort revealed a significant inverse correlation between age and
rate of esophagitis for both grade levels. The same association was
noted in the MROQC cohort, which validated these results. There was no
significant association between age and pneumonitis.

The authors comment that, "Our study demonstrates significantly
decreased incidence of radiation esophagitis in elderly patients. This
finding remained significant even after adjusting for esophageal dose,
concurrent chemotherapy, history of smoking, and performance status. In
patients who are never smokers with good performance status, who
received high doses of radiation to the esophagus with concurrent
chemotherapy, the probability of esophagitis for a 70 year old is
approximately one-third that of an identical 50 year old patient. Pattern of care studies suggest that the elderly are being undertreated
for various malignancies including lung cancer, independent of other
variables including performance status. Our study undermines this
practice and supports standard definitive treatment for the elderly with
good performance status."

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